041311handouts - alabama department of public …...4/5/2011 1 overview of pediatric physical...

4/5/2011

1

Overview of Pediatric Physical AssessmentOverview of Pediatric Physical Assessment

Produced by the Alabama Department of Public HealthVideo Communications and Distance Learning DivisionProduced by the Alabama Department of Public HealthVideo Communications and Distance Learning Division

Satellite Conference and Live WebcastWednesday, April 13, 2011

1:00 - 4:00 p.m. Central Time

Satellite Conference and Live WebcastWednesday, April 13, 2011

1:00 - 4:00 p.m. Central Time

FacultyFaculty

Karen M. Landers, MD, FAAPAssistant State Health Officer

Pediatric ConsultantAlabama Department of Public Health

Karen M. Landers, MD, FAAPAssistant State Health Officer

Pediatric ConsultantAlabama Department of Public Healthaba a epa t e t o ub c ea taba a epa t e t o ub c ea t

Essentials of PediatricPhysical AssessmentEssentials of PediatricPhysical Assessment

• Thorough history

• Properly interpreted vital signs

• Properly evaluated developmental

• Thorough history

• Properly interpreted vital signs

• Properly evaluated developmental• Properly evaluated developmental

and growth parameters

• Focused physical assessment

• Properly evaluated developmental

and growth parameters

• Focused physical assessment

Essentials of PediatricPhysical AssessmentEssentials of PediatricPhysical Assessment

• Anticipatory guidance/preventive

health

– Immunizations

• Anticipatory guidance/preventive

health

– Immunizations

– Ingestions

– Injuries

• Problem list and plan

– Ingestions

– Injuries

• Problem list and plan

General Points About Taking a History

General Points About Taking a History

• Chief complaint

• Onset of problem

• Duration of problem

• Chief complaint

• Onset of problem

• Duration of problem• Duration of problem

• Progression of problem

• Aggravating or alleviating factors

• Associated manifestations

• Duration of problem

• Progression of problem

• Aggravating or alleviating factors

• Associated manifestations

General Points ContinuedGeneral Points Continued• Functional impairment

– Changes in eating patterns

– Playfulness

• Functional impairment

– Changes in eating patterns

– Playfulness

– School performance

– Sleep habits

– School performance

– Sleep habits

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General PointsGeneral Points• Allergic history

• Medication history

• Immunization history

• Hospitalization and/or accidents

• Allergic history

• Medication history

• Immunization history

• Hospitalization and/or accidentsHospitalization and/or accidents

• Birth history

• Developmental milestones

• Family history

• Social history

Hospitalization and/or accidents

• Birth history

• Developmental milestones

• Family history

• Social history

General Appearance of Infant or Child

General Appearance of Infant or Child

• Activity or movement

• Facial features

• Behavior when examiner enters room

• Activity or movement

• Facial features

• Behavior when examiner enters room• Behavior when examiner enters room

– Developmentally appropriate

• Nutritional status

• Hygiene

• Behavior when examiner enters room

– Developmentally appropriate

• Nutritional status

• Hygiene

Approach to the Pediatric PatientApproach to the Pediatric Patient

• Age appropriate interaction

– Gentle and engaging

– Nonthreatening

• Age appropriate interaction

– Gentle and engaging

– Nonthreatening– Nonthreatening

– Take the path of least resistance

– Quiet and soothing

– Nonthreatening

– Take the path of least resistance

– Quiet and soothing

Approach to the Pediatric PatientApproach to the Pediatric Patient

– Use observation liberally while

taking the history

– Always inform the patient of what

– Use observation liberally while

taking the history

– Always inform the patient of what y p

you are about to do and never lie

to the patient

– Minimize the use of the exam table

in infants and younger children

y p

you are about to do and never lie

to the patient

– Minimize the use of the exam table

in infants and younger children

Growth and Development Parameters


• Use current growth charts plotting BMI

• Weigh appropriately

• Use current growth charts plotting BMI

• Weigh appropriately

– Dry diaper

• Check height by placing infant on measuring table with head at the end of the board

– Have older children take off shoes

– Dry diaper

• Check height by placing infant on measuring table with head at the end of the board

– Have older children take off shoes



• Measure head circumference up to

two years old placing measuring tape

above eyebrows and measuring

• Measure head circumference up to

two years old placing measuring tape

above eyebrows and measuring

around to occipital prominencearound to occipital prominence

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Growth Parameters and Areas of Concern


• Know normal weight gains for age

• Usual expected height velocity for

age

• Know normal weight gains for age

• Usual expected height velocity for

ageg

• Family information specifically about

parental stature

• Consider children born in other

countries

g

• Family information specifically about

parental stature

• Consider children born in other

countries



• Be concerned about head

circumferences at extremes and

height/weight crossing percentiles

• Be concerned about head

circumferences at extremes and

height/weight crossing percentiles

Developmental Assessment for Age General InformationDevelopmental Assessment for Age General Information• Use standardized developmental

screening tools assessing gross

motor, fine motor, language,

• Use standardized developmental

screening tools assessing gross

motor, fine motor, language,

sensory, and social development

• Be “open-ended” with questions

• Use observation during the history to

fill-in developmental information

sensory, and social development

• Be “open-ended” with questions

• Use observation during the history to

fill-in developmental information

Developmental Assessment for Age General InformationDevelopmental Assessment for Age General Information• Ask about hearing concerns even

with newborns

• Be alert to normal acquisition of

• Ask about hearing concerns even

with newborns

• Be alert to normal acquisition of q

language milestones

• Screen at every well infant and child

visit

q

language milestones

• Screen at every well infant and child

visit

Measure Vital Signs and Know How to Interpret Age

Appropriate Variations


Appropriate Variations• Temperature

– Can use tympanic thermometers to

• Temperature

– Can use tympanic thermometers toCan use tympanic thermometers to

avoid invasive techniques such as

rectal thermometers past the

newborn and early infant ages

Can use tympanic thermometers to

avoid invasive techniques such as

rectal thermometers past the

newborn and early infant ages




Appropriate Variations• Pulse

– Apical less than 2 years old/count

• Pulse

– Apical less than 2 years old/countApical less than 2 years old/count

for one minute

Apical less than 2 years old/count

for one minute

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Appropriate Variations• Respiratory Rate

– Count for one minute and be aware

• Respiratory Rate

– Count for one minute and be awareCount for one minute and be aware

of periodic and abdominal

breathing in infants

Count for one minute and be aware

of periodic and abdominal

breathing in infants

A Word About Blood Pressure Measurement

A Word About Blood Pressure Measurement

• Select a cuff with a width that covers

2/3 of the upper arm and a length of

the bladder that encircles 100% of

• Select a cuff with a width that covers

2/3 of the upper arm and a length of

the bladder that encircles 100% of

the arm without overlap

• Know age appropriate normals

the arm without overlap

• Know age appropriate normals

Respiratory RatesRespiratory Rates• If possible measure in sleeping

infants

• Be aware that fever or crying will

elevate the rate significantly

• If possible measure in sleeping

infants

• Be aware that fever or crying will

elevate the rate significantlyelevate the rate significantly

– Premature infants: 40-60

– Newborns: 30-50

– Toddlers: 20-30

elevate the rate significantly

– Premature infants: 40-60

– Newborns: 30-50

– Toddlers: 20-30

Respiratory RatesRespiratory Rates– School age children: 15-25

– Adolescents: 12-20

– School age children: 15-25

– Adolescents: 12-20

Blood Pressure ParametersBlood Pressure Parameters• Specific charts are available in

reference materials

– Harriet Lane Handbook of

Pediatrics

• Specific charts are available in

reference materials

– Harriet Lane Handbook of

PediatricsPediatrics

– NIH guidelines

– Other authoritative sources

Pediatrics

– NIH guidelines

– Other authoritative sources

Blood Pressure ParametersBlood Pressure Parameters• General guidelines

– Newborn: 50-70 mmHg

– Infant: 70-100 mmHg

• General guidelines

– Newborn: 50-70 mmHg

– Infant: 70-100 mmHg

– Toddler to 5 years: 80-100 mmHg

– Elementary school: 80-120 mmHg

– Adolescent (13 years and above):

110-120 mmHg

– Toddler to 5 years: 80-100 mmHg

– Elementary school: 80-120 mmHg

– Adolescent (13 years and above):

110-120 mmHg

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Heart RateHeart RateAge Range of Rate

Birth 70-190

0-6 months 130

6-12 months 115

1-2 years 110

2-6 years 80-130

6-10 years 75-115

10-14 years 70-110

14 and above 65-100

Focus Points for theNeonatal ExaminationFocus Points for theNeonatal Examination

• Fontanels

• Skin color

• Facies

• Fontanels

• Skin color

• Facies

• Tone

• Symmetry

– Movement, respiratory effort, abdomen

• Reflexes

• Tone

• Symmetry

– Movement, respiratory effort, abdomen

• Reflexes

Neonatal Reflexes and When They DisappearNeonatal Reflexes and When They Disappear

• Stepping: 2 months

• Moro: 3 months

• Rooting: 3 4 months

• Stepping: 2 months

• Moro: 3 months

• Rooting: 3 4 months• Rooting: 3-4 months

• Palmar grasp: 3-4 months

• Rooting: 3-4 months

• Palmar grasp: 3-4 months

Neonatal Reflexes and When They DisappearNeonatal Reflexes and When They Disappear

• Tonic neck: 4-6 months

• Plantar grasp: 8-10

• Sucking: 10 12 months

• Tonic neck: 4-6 months

• Plantar grasp: 8-10

• Sucking: 10 12 months• Sucking: 10-12 months

• Babinski: 2 years

• Sucking: 10-12 months

• Babinski: 2 years

Some Information on WeightSome Information on Weight• Newborns may lose up to 10% of

their birth weight in the first 3-4 days

• Newborns gain ½ to 1 ounce per day

after that time

• Newborns may lose up to 10% of

their birth weight in the first 3-4 days

• Newborns gain ½ to 1 ounce per day

after that time

• Excessive or poor weight gain needs

to be addressed

• Excessive or poor weight gain needs

to be addressed

Some Information on WeightSome Information on Weight• Infants generally double their birth

weight by 5 months and triple it by

one year

• Infants generally double their birth

weight by 5 months and triple it by

one year

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Be Alert for Congenital Anomalies

Be Alert for Congenital Anomalies

Some Specifics in NeonatesSome Specifics in Neonates• Anterior and posterior fontanels

– Anterior closes between 12 - 18

months

P t i l b 2 5 th

• Anterior and posterior fontanels

– Anterior closes between 12 - 18

months

P t i l b 2 5 th– Posterior closes by 2-5 months

• Red reflex

• Sacral dimples

• Mongolian spots

– Posterior closes by 2-5 months

• Red reflex

• Sacral dimples

• Mongolian spots

Sacral DimpleSacral Dimple Mongolian SpotMongolian Spot

Mongoliangblue spots

Congenital NevusCongenital Nevus System by SystemPhysical Examination

System by SystemPhysical Examination

• Integument

• HEENT

• Neck

• Integument

• HEENT

• Neck• Neck

• Cardiovascular

• Pulmonary

• Neck

• Cardiovascular

• Pulmonary

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• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Gastrointestinal

• Genitourinary

• Musculoskeletal• Musculoskeletal

• Neurologic

• Musculoskeletal

• Neurologic

IntegumentaryIntegumentary• Inflammatory

• Viral

• Bacterial

• Inflammatory

• Viral

• Bacterial

• Congenital

• Allergic

• Other

• Congenital

• Allergic

• Other

General Principles of Examination of the Skin


• Color

– Pallor

– Jaundice

• Color

– Pallor

– Jaundice

• Normal after 24 hours in newborn up to 7-10 days but abnormal afterwards

– Variations in skin pigmentation

• Normal after 24 hours in newborn up to 7-10 days but abnormal afterwards

– Variations in skin pigmentation



• Texture, turgor

• Rashes

• Lesions

• Texture, turgor

• Rashes

• Lesions

• Hair and nails• Hair and nails

Some Descriptive Terms of RashesSome Descriptive Terms of Rashes

• Macular

• Papular

• Blanch with pressure

• Macular

• Papular

• Blanch with pressure• Blanch with pressure

• Excoriated

• Hemorrhagic

• Blanch with pressure

• Excoriated

• Hemorrhagic

Some Descriptive Terms of LesionsSome Descriptive Terms of Lesions

• Blistering

• Cystic

• Hives or wheals

• Blistering

• Cystic

• Hives or wheals

• Scaling• Scaling

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Some Descriptive Terms of LesionsSome Descriptive Terms of Lesions

• Crusting/scab forming

• Scars

• Other

• Crusting/scab forming

• Scars

• Other

– Congenital, neoplastic– Congenital, neoplastic

CandidiasisCandidiasis

Chicken PoxChicken Pox Herpes SimplexHerpes Simplex

EczemaEczema HemangiomaHemangioma

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MiliaMilia UrticariaUrticaria

ImpetigoImpetigo Contact DermatitisContact Dermatitis

RingwormRingworm ScabiesScabies

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SeborrheaSeborrhea Café au LaitCafé au Lait

Lymph NodesLymph Nodes• Small, nontender, English pea size,

soft, and freely moveable lymph

nodes are common primarily in the

cervical region

• Small, nontender, English pea size,

soft, and freely moveable lymph

nodes are common primarily in the

cervical region

• Check cervical, axillary, inguinal

region for lymph nodes

• Check cervical, axillary, inguinal

region for lymph nodes

Enlarged Lymph NodeEnlarged Lymph Node

Head and NeckHead and Neck• Check for symmetry, head control in

infants, posture to one side (an

indicator of torticollis), range of

motion

• Check for symmetry, head control in

infants, posture to one side (an

indicator of torticollis), range of

motion

• Feel the anterior and posterior

fontanels

• Feel the anterior and posterior

fontanels

Head and NeckHead and Neck

• Older infant

– Flexion, extension, rigidity

– Thyroid enlargement, branchial

• Older infant

– Flexion, extension, rigidity

– Thyroid enlargement, branchial

cleft cysts cleft cysts

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EyesEyes• Check for shape and symmetry

• Note the color of the conjunctiva

• Evaluate extra ocular movements

Ch k ill fl

• Check for shape and symmetry

• Note the color of the conjunctiva

• Evaluate extra ocular movements

Ch k ill fl• Check pupillary reflexes

• Fundiscopic for red reflex

• Appropriate vision testing in the

clinical setting

• Check pupillary reflexes

• Fundiscopic for red reflex

• Appropriate vision testing in the

clinical setting

StrabismusStrabismus

ConjunctivitisConjunctivitis Reflex PathologyReflex Pathology

EarsEars

• Evaluate shape, position

• View internal structures

• Newborn hearing screening and

• Evaluate shape, position

• View internal structures

• Newborn hearing screening and

ongoing assessment of hearing

including language development

ongoing assessment of hearing

including language development

Normal and Abnormal Tympanic MembraneNormal and Abnormal Tympanic Membrane

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NoseNose

• Structure, position

• Evidence of grunting or flaring

• Color of any drainage, foul odor,

• Structure, position

• Evidence of grunting or flaring

• Color of any drainage, foul odor,

color of mucosa, location of septumcolor of mucosa, location of septum

ThroatThroat• Color of lips, presence of fissures

• Teeth

– Number and condition

• Color of lips, presence of fissures

• Teeth

– Number and condition

• Gums

– Color and condition

• Tongue

– Midline, color, graphic patterns

• Gums

– Color and condition

• Tongue

– Midline, color, graphic patterns

ThroatThroat• Integrity of palate and location of

uvula

• Tonsillar size

• Integrity of palate and location of

uvula

• Tonsillar size

Enlarged TonsilsEnlarged Tonsils

Geographic TongueGeographic Tongue Chest and BackChest and Back• Inspect size, shape, symmetry along

with movement

• Note any distress including use of

accessory muscles

• Inspect size, shape, symmetry along

with movement

• Note any distress including use of

accessory musclesaccessory muscles

• Note symmetry of nipples and any

breast development

• Check for spinal curvature

accessory muscles

• Note symmetry of nipples and any

breast development

• Check for spinal curvature

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Pectus ExcavatumPectus Excavatum

Depression in sternum


Normal heart position


Depression pushes heart to the side

Pectus CarinatumPectus Carinatum

HeartHeart• Palpate over the valvular areas

• Determine the PMI

• Rate

Hi h th d lt

• Palpate over the valvular areas

• Determine the PMI

• Rate

Hi h th d lt– Higher than adults

• Rhythm noting that infants and

children will have variation with

respiration

– Higher than adults

• Rhythm noting that infants and

children will have variation with

respiration

HeartHeart• Murmurs

– Systolic murmurs can be normal

– Diastolic murmurs are always

b l

• Murmurs

– Systolic murmurs can be normal

– Diastolic murmurs are always

b labnormal

• S1 and S2

abnormal

• S1 and S2

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MurmursMurmurs• Classic description

– Grade I-VI

– Descriptive terms

• Classic description

– Grade I-VI

– Descriptive terms

• Crescendo, decrescendo, harsh,

blowing, soft

• Crescendo, decrescendo, harsh,

blowing, soft

LungsLungs• Auscultation

– Do not confuse upper airway

sounds with lung sounds

Equal breath sounds

• Auscultation

– Do not confuse upper airway

sounds with lung sounds

Equal breath sounds– Equal breath sounds

– Rales, ronchi, wheezing

– Equal breath sounds

– Rales, ronchi, wheezing

AbdomenAbdomen• Inspect the shape

• Auscult for bowel sounds

– Normal should be heard every

10 30 seconds

• Inspect the shape

• Auscult for bowel sounds

– Normal should be heard every

10 30 seconds10 - 30 seconds

• Palpate for masses, tenderness

10 - 30 seconds

• Palpate for masses, tenderness

Umbilical HerniaUmbilical Hernia

GenitaliaGenitalia• Males

– Presence or absence of

circumcision

Penis

• Males

– Presence or absence of

circumcision

Penis– Penis

– Testes

• Descended, undescended, or

retractile

– Penis

– Testes

• Descended, undescended, or

retractile

GenitaliaGenitalia– Location of urethral meatus

– Tanner staging

– Anal structure

– Location of urethral meatus

– Tanner staging

– Anal structure

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HerniasHerniasA B

C D E

Glanular

Subcoronal

Distal penile

Midshaft

Anterior(50%)

Middle(30%)

HypospadiusHypospadius

Anterior(50%)

Middle(30%)

Proximal penile

Penoscrotal

Scrotal

Perineal

(30%)

Posterior(20%)

(30%)

Posterior(20%)

GenitaliaGenitalia• Females

– Labia majora and minora noting

any labial fusion in young infants

or young girls

• Females

– Labia majora and minora noting

any labial fusion in young infants

or young girlsor young girls

– Urethral orifice

or young girls

– Urethral orifice

GenitaliaGenitalia

– Vaginal orifice along with any

evidence of imperforate hymen or

other abnormalities

Tanner stage

– Vaginal orifice along with any

evidence of imperforate hymen or

other abnormalities

Tanner stage– Tanner stage

– Anus

– Tanner stage

– Anus

Normal and Abnormal HymensNormal and Abnormal Hymens ExtremitiesExtremities• Range of motion with specific

concerns for hip movement in infants

• Femoral pulses

J i t th t bilit lli

• Range of motion with specific

concerns for hip movement in infants

• Femoral pulses

J i t th t bilit lli• Joint warmth, stability, swelling,

tenderness, clubbing of fingers

• Gait

• Genu valgum or varum

• Joint warmth, stability, swelling,

tenderness, clubbing of fingers

• Gait

• Genu valgum or varum

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Evaluation of Hip Mobilityin Infants

Evaluation of Hip Mobilityin Infants

Genu VarumGenu Varum

Genu ValgumGenu Valgum Neurologic Assessment for AgeNeurologic Assessment for Age• Considerable information can be

gained by watching the child during

the history gathering portion of the

exam

• Considerable information can be

gained by watching the child during

the history gathering portion of the

exam

• Reflexes-biceps, triceps, patellar,

achilles

• Reflexes-biceps, triceps, patellar,

achilles

Neurologic Assessment for AgeNeurologic Assessment for Age

• Assess cranial nerves

• For older infants and children,

cerebellar function

• Assess cranial nerves

• For older infants and children,

cerebellar function

Sources for Photographs and Images


• Photographic images obtained for

this presentation are used with

permission and solely for medical

• Photographic images obtained for

this presentation are used with

permission and solely for medical

educational purposeseducational purposes

4/5/2011

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• Sources

– www.rainbowpediatrics.net

– www slideworld org

• Sources

– www.rainbowpediatrics.net

– www slideworld org– www.slideworld.org

– Kinsburg, K., M.D.

– www.slideworld.org

– Kinsburg, K., M.D.

041311handouts - alabama department of public …...4/5/2011 1 overview of pediatric physical...

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